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Driving a National Performance Improvement Agenda in Hospice & Palliative Care
Sally Norton RN, PhD, FPCN, FAAN October 21, 2016
Acknowledgments MWM Project Leadership and Authors
Measuring What Matters (MWM) Co-chairs: • David Casarett, MD MA, University of Pennsylvania
• Sally Norton, PhD RN FPCN FAAN, University of Rochester
MWM Technical Advisory Panel Co-chair:
• Sydney Dy, MD, Johns Hopkins University
• Susan McMillan, PhD RN FAAN, University South Florida
MWM Clinical User Panel Co-chairs:
• Keela Herr, PhD RN AGSF FAAN, University of Iowa
• Joseph Rotella, MD MBA FAAHPM, AAHPM
AAHPM staff and consultants
• Katherine Ast, MSW LCSW & Dale Lupu, PhD MPH
HPNA Staff
• June Lunney, PhD RN
Disclosures (All authors listed above had no relevant financial relationships
to disclose with the following exceptions: Rotella and Lupu are
contractors and receive consulting fees from AAHPM.)
Objectives
1. Describe one rationale for the national AAHPM and HPNA joint task
force, Measuring What Matters.
2. State 3 issues common in palliative care that hinder national
benchmarking of quality indicators.
3. Identify 2 palliative care quality measures that will be useful in your
system.
MWM Goal
The goal of MWM was to select a small set of measures that are
scientifically rigorous, meaningful to patients and families receiving
hospice and palliative care, could be used broadly across many settings
and group.
In the short term: Using recommended measures internally is to our
own organizations.
In the longer term: Allows us to develop data repositories with shared
measures and data which will, in turn, support the further development
of the field of hospice and palliative care.
Environment changing fast
Government
• Affordable Care Act
• CMS regulations
Health care systems
• Consolidating
• Integrating post-acute care
continuum
Emerging models
• Population health
management
• Value-based purchasing
Healthier Populations
Lower Costs
Higher Quality
Patient Care
Reasons to measure quality
Purpose Example measures
Justify need for a palliative care program
Extended hospitalizations, intensive care unit stays near the end of life
Demonstrate where improvements are needed
Pain scores Documentation of end-of-life discussions
Evaluate impact of new programs or quality improvement
Patient/family perceptions of care
Monitor care for deficiencies, worsening care
Patient safety reporting on pain issues Scorecard including pain scores
Help patients, families, providers make informed choices
Hospice quality reporting, including patient/family perceptions of care
Dy S J Support Onc 2013; Kamal A et al J Pain Symptom Manage 2014
Dy S. Measuring the quality of palliative care and supportive oncology: principles and practice. J Support Onc. Dec. 2013.
Seize the opportunity
•Problem – Bewildering array of published measures
(e.g. 15 measures about advance care planning and
preferences)
•Opportunity – Focus providers on a few of the best,
so they can begin to share and benchmark
•Problem – Few palliative care measures included in
the national quality programs
•Opportunity – Set the agenda for what should be
included
What do we mean by Measuring What Matters?
Measuring What Matters (MWM) is a consensus recommendation for a portfolio of performance measures for all hospice and palliative care programs to use for program improvement. http://aahpm.org/quality/measuring-what-matters
Detail on Process Steps
Indicators mapped to National Consensus Project (NCP)
domains
TAP rated published measures on their scientific soundness
CUP rated measures based on 3 dimensions of importance:
• How MEANINGFUL is this for patients/families?
• How ACTIONABLE is this for providers/organizations?
• How large is the POTENTIAL IMPACT?
Draft list of 12 measures sent to AAHPM and HPNA members,
organizations & patient advocacy groups, to elicit feedback
Feedback received from 264 individuals and 27 organizations
MWM indicator selection process
Identify candidate measures
• Identifies 75 published measures
Technical Advisory
Panel Review
• Narrows to 34 technically strongest measures
Clinical User Panel Review
• Selects 12 best measures
AAHPM & HPNA member
ranking, public input
•Prioritizes top 10 measures
Gaps Identified
2 NCP domains have no recommended measures
– NCP Domain 4: Social Aspects of Care
• None met rating criteria
– NCP Domain 6: Cultural Aspects of Care
• None specific to palliative care found in literature
Few truly cross-cutting measures
Existing measures mostly specified for specific populations (eg.
cancer or hospice)
Need broad denominator definition
10 measures selected
Dy, Kiley, Ast, Lupu, Norton,
McMillan, Herr, Rotella,
Casarett. (2015) Measuring
What Matters: Top-Ranked
Quality Indicators for
Hospice and Palliative Care
Journal of pain and symptom
management 49.4: 773-781.
Summary handout
Start your plan Identify priorities in your setting [who, what, when, how, why]
Align with existing requirements
•Hospices: start with measures already in HIS
•Hospital based PC: select from MWM to meet TJC advanced
certification requirements
Integrate into dashboards for leadership or other stakeholders
Advocate for alignment of state, regional, payor efforts with
MWM indicators
Tips on starting with MWM
Keep it simple
Make sure you look CAREFULLY at measure
definitions
If at all possible, don’t change the definitions
Start with 2 or 3 measures, not full list
Choose measures considering
structure/process/outcome
Resources to help advance a quality improvement agenda in your setting
PEACE measures
http://www.med.unc.edu/pcare/resources/PEACE-Quality-
Measures
IHI open school
http://www.ihi.org/education/IHIOpenSchool/Pages/default.
aspx
IHI uses the Model for
Improvement* as the
framework to guide
improvement work
Learn fundamentals of
the model and testing
changes on a small
scale using Plan-Do-
Study-Act (PDSA)
cycles
Source: Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.
Hospice HIS indicator convergence
1. NQF #1617 Patients Treated with an Opioid
who are Given a Bowel Regimen
2. NQF #1634 Pain Screening
3. NQF #1637 Pain Assessment
4. NQF #1638 Dyspnea Treatment
5. NQF #1638 Dyspnea Screening
6. NQF #1641 Treatment Preferences
7. Modified NQF #1647 Spiritual Concerns
Addressed
TJC Advanced Certification in Palliative Care Program
Currently, any two measures permissible
TJC working to specify and test select MWM
measures to fit TJC Advanced Certification in
Palliative Care Program
In several years, expect several measures to be
mandated
Set priorities &
goals Develop &
test measures
Endorse & harmonize measures
Health Info Tech
specification & embed in EMR
Implementation strategies &
Technical assistance Data
aggregation, benchmarks,
registries
Public reporting
Public policy, including payment
incentives
Quality & Affordability
Continuously evaluate health &
health care
Adapted from the Consumer-Purchaser Disclosure Project: Idealized Framework for Quality and Cost Transparency for High-Value Care, QASC, January 2008
Quality Improvement
National Consensus
Project
Creative tensions
Process or outcome measures?
Specialty focus or generalist care focus?
Perfection or pragmatism?
Quality improvement or accountability?
Hospice or palliative care?
Medical model or interdisciplinary?
Ongoing Priorities & Challenges
defining the denominator(s) for palliative care
quality indicators
electronic health records
palliative care registries
methods for measurement across settings
and data sources
further development of patient/family-
reported outcome indicators